Heart Care

Better Long-Term Outcomes with Medications versus Angioplasty

There are some advantages to artery-opening angioplasty over medication treatment for people with heart disease, but those advantages disappear within three years, according to a report in the New England Journal of Medicine.

Angioplasty does offer a higher quality of life for months to a couple of years, says study leader Dr. William S. Weintraub, chief of cardiology at the Christiana Health Care System in Newark, Delaware.

In the COURAGE trial, the researchers tested angioplasty, with stent implants, against medication treatment for 2,287 people with stable coronary disease.

Earlier analysis found improved quality of life for those having the artery-opening procedure that is formally called percutaneous coronary intervention (PCI).

The new report found that by 36 months, there was no significant difference in health status between the two treatment groups.

"What one can say is that for people with chronic, stable coronary disease, PCI can be deferred," Dr. Weintraub says. "They can continue on medication aimed at their specific risk factors - hypertension, lipid disorders, diabetes - and should be encouraged to have a good lifestyle, with exercise, smoking cessation, and weight control."

Doctors Assess Needs

A decision to have PCI can depend on how an individual feels, says Dr. Weintraub.

"If people say, 'My pain is so bad I can't function,' that is one thing. If people say, 'I have angina, but I'm doing OK,' that's another," he says.

Angina is the chest pain that is a chief symptom of coronary disease.

Cost could be a factor in some decisions, notes Dr. Weintraub. PCI is more expensive than medication therapy, but the current report does not mention money.

However, a preliminary cost-benefit analysis presented by Dr. Weintraub last November found that "PCI adds about $10,000, without any significant gain in years of survival or quality of life."

The cost of one year of life added by PCI varies from $150,000 to $300,000, the analysis found.

The cost of PCI versus medication treatment must be considered "by society as a whole," he says. "But when a doctor talks to a patient, the doctor is an advocate for that patient."

"Paying the cost out of pocket gives one a different point of view," he says.

The attitude of medical insurance providers does matter, says Dr. Eric D. Peterson, at the Duke Clinical Research Institute. Insurance companies now are quite willing to pay for PCI, and "until that category is changed, the effect of this study will be modest," he says.

Medical Therapy for Stable Heart Disease

The COURAGE results show that PCI should not be the treatment of choice for people with stable heart disease, says Dr. Peterson.

"We have justified angioplasty for years by saying it is of great benefit to patients," he says. "This study shows no survival benefit and shows that the benefit in regard to symptom relief is temporary. Medical therapy should be considered for all patients with stable angina, unless they have severe pain when diagnosed."

The fact that 21 percent of those in the COURAGE trial who started on medication treatment eventually had PCI shows that a decision on surgery can safely be delayed, he says.

The hazards as well as the benefits of PCI should be considered when a decision is made, notes Dr. Peterson.

Of 1,000 persons undergoing PCI, two will die, 28 will have heart attacks related to the procedure, 60 to 90 will have improved symptom relief, and 800 will have no noticeable benefit above that given by drug treatment, his editorial explains.

November 2008

Understanding Angioplasty and Stents

Percutaneous transluminal coronary angioplasty (PTCA) is performed to open blocked coronary arteries caused by coronary artery disease (CAD) and to restore arterial blood flow to the heart tissue without open-heart surgery.

PTCA is also called percutaneous coronary intervention, or PCI.

A special catheter (long hollow tube) is inserted into the coronary artery to be treated. This catheter has a tiny balloon at its tip. The balloon is inflated once the catheter has been placed into the narrowed area of the coronary artery. The inflation of the balloon compresses the fatty tissue in the artery and makes a larger opening inside the artery for improved blood flow.

The use of fluoroscopy (a special type of x-ray, similar to an x-ray “movie”) assists the physician in the location of blockages in the coronary arteries as the contrast dye moves through the arteries. A small sample of heart tissue (called a biopsy) may be obtained during the procedure to be examined later under the microscope for abnormalities.

A technique called intravascular ultrasound (IVUS), a technique that uses a computer and a transducer that sends out ultrasonic sound waves to create images of the blood vessels, may be used during PTCA. The use of IVUS provides direct visualization and measurement of the inside of the blood vessels and may assist the physician in selecting the appropriate size of balloons and/or stents, to ensure that a stent, if used, is properly opened, or to evaluate the use of other angioplasty instruments.

In the past few years, many refinements have been developed in the PTCA procedure. One common procedure used in PTCA is stent placement. A stent is a tiny, expandable metal coil that is inserted into the newly-opened area of the artery to help keep the artery from narrowing or closing again.

Once the stent has been placed, tissue will begin to form over it within a few days after the procedure. The stent will be completely covered by tissue within a month or so. It is necessary to take a medication, such as aspirin or clopidogrel (Plavix™), which decreases the “stickiness” of platelets (a type of blood cells that clump together to form clots to stop bleeding), in order to prevent blood clots from forming inside the stent.

Newer stents (drug-eluting stents, or DES) are coated with medication to prevent the formation of scar tissue inside the stent. These drug-eluting stents release medication within the blood vessel itself. This medication inhibits the overgrowth of tissue that can occur within the stent. The effect of this medication is to deter the narrowing of the newly stented blood vessel.

If scar tissue does form inside the stent, radiation therapy (called brachytherapy) may be used to clear the scarred area and open up the vessel.

Always consult your physician for more information.

Online Resources

(Our Organization is not responsible for the content of Internet sites.)